tbuckley/cabot-search huggingface dataset:
Abstract 11960: Right Ventricular Diameter in Risk Stratification of Sudden Cardiac Death
Authors: Hao Huang, Sijing Cheng, Yu Deng, Xi Liu, Yu Yu, Wei Hua
Journal: Circulation (2022)

Introduction: Right ventricular (RV) abnormalities have been linked with the risk of sudden cardiac death (SCD) in general population. This study was designed to evaluate the additional value of right ventricular diameter (RVD) in predicting life-threatening ventricular tachycardia (VT)/ventricular fibrillation (VF) in patients with implantable cardioverter-defibrillators (ICD). Hypothesis: We hypothesized that higher value of RVD would be an easily accessible predictor in decision-making of ICD implantation. Methods and Results: We enrolled 954 chronic heart failure patients, with quantitative measurements of echocardiograms obtained before ICD implantation, and then divided them according to the median level of RVD. Fine-Gray subdistribution and Cox proportional hazard regression analyses were performed to estimate the predictive value of RVD in sustained VT/VF vs. non-arrhythmic mortality (defined as death without prior sustained VT/VF), respectively. Patients with higher median level of RVD had a significantly higher incidence of VT/VF (32.9% versus 26.7%; P=0.041) over the median follow-up of 2.83 years (interquartile range: 1.33-5.27 years). After adjustment for multiple clinically relevant variables, high RVD levels were significantly associated with an increased risk of VT/VF (per 1 SD increase, hazard ratio=1.16; 95% CI, 1.05-1.27; P=0.003), but not non-arrhythmic mortality (per 1 SD increase, hazard ratio=0.97; 95% CI, 0.82-1.14; P=0.680). When adding RVD to the Seattle Proportional Risk Model (SPRM) and the MADIT-ICD VT/VF risk score, the combined models yielded significant improvement in discrimination for VT/VF. Elevated RVD also contributed to residual risk beyond left ventricular parameters including left ventricular end-diastolic diameter (LVEDD) and left ventricular ejection fraction (LVEF). The restricted mean survival time measure indicated that life gained with ICD implantation in RVD higher group were 11.0, 28.4 and 29.1 days more than their lower counterparts in one, two, and three years’ time. Conclusions: RVD is associated with a significantly increased risk of sustained VT/VF in chronic heart failure patients, and provides greater prognostic power when combined with current risk assessment tools.
Abstract 12029: The Impact of the Myocardial Bridge on Coronary Functional Test in Patients With Ischemia With Non-Obstructive Coronary Arteries
Authors: Hiroki Teragawa, Chikage Oshita, Yuko Uchimura
Journal: Circulation (2022)

Introduction: The possibility of myocardial bridge (MB) causing chest pain has been widely reported; however, the effect of MBs on coronary microvessels has not been thoroughly investigated. Hypothesis: Thus, this study evaluated the effects of MB on epicardial coronary artery and coronary microvascular function during coronary angiography (CAG) and coronary function tests (CFT) in patients with ischemia with non-obstructive coronary arteries (INOCA). Methods: This study included 57 patients with INOCA who underwent CAG and CFT to evaluate chest pain. In CFT, acetylcholine was first administered intracoronarily in a stepwise manner, followed by chest symptoms, electrocardiographic changes [Editor1] and CAG. Positive coronary spasm was defined as coronary vasoconstriction of &gt;90% on CAG accompanied by chest symptoms or electrocardiographic ST-T changes. After nitroglycerin administration, CAG was performed to assess MB, which is defined as the systolic narrowing of the coronary artery diameter by &gt;20% compared to that in diastole. Coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were subsequently obtained by transvenous adenosine triphosphate infusion using a pressure wire. Coronary microvascular vasodilatory dysfunction (CMD) was defined as CFR of &lt;2.0 or IMR of ≥25 units. Results: Of the 57 patients, 13 (23%) had MB. The CAG and coronary CFT results in the MB (+) and MB (–) groups are shown below. Conclusions: These findings suggest that MB predisposes to coronary spasms in patients with INOCA. Conversely, MBs may have a limited effect on microvessels, particularly in such patients.
Abstract 12213: A Description of Left Atrial Appendage Morphologies by Race
Authors: Madeline Lee, Alexander Quinn, Matthew Bocchese, Rebecca Garber, Pravin Patil, Thomas A Dewland, Isaac R Whitman
Journal: Circulation (2022)

Introduction : The left atrial appendage (LAA) is the origin of most thromboemboli in patients with atrial fibrillation (AF). Certain LAA morphologies are associated with higher risk of thrombus formation and stroke. Blacks with AF suffer more ischemic strokes than non-Blacks despite adjustment for conventional stroke risk factors and differences in anticoagulation prescription. The association of certain LAA morphologies with race as a contributing explanation for the racial difference in stroke risk has not been examined. We hypothesized that, among those with AF, Blacks have higher risk LAA morphologies compared to non-Blacks. Methods : We performed a retrospective analysis of consecutive patients with AF who underwent a contrast-enhanced CT scan in preparation for Watchman device placement to determine LAA morphology. Based on prior literature, we assigned a score to each morphology based on relative risk of stroke associated with each morphology: chicken wing, 1 (lowest risk, reference); windsock or cactus, 4; and cauliflower, 8. Mean scores among Blacks vs non-Blacks, defined as White, Asian, or Hispanic, were compared using Students T-test. Results : Among 85 patients (Black, n=36), there was no significant difference in the proportion of individuals with the low risk chicken wing morphology between races (29% Black versus 36% non-Black, p = 0.69). However, Blacks were more likely to have the high risk cauliflower morphology (n=5, 6% versus n=1, 1%, p=0.04). The summative mean score for morphology-associated stroke risk was higher among Blacks (2.1 vs 2.5, p=0.017) ( Figure ). Conclusions : Black patients with AF had higher-risk LAA morphologies compared to non-Black patients. These findings may explain the previously observed racial differences in AF-associated stroke risk.Figure: Distribution of LAA morphologies by Black versus Non-Black and difference in summative relative risk between Black and Non-Black patients.
Abstract 12203: Safety and Effectiveness of Pre-Procedure Imaging for Percutaneous Left Atrial Appendage Occlusion: Insights From the National Cardiovascular Data Registry (NCDR) LAAO Registry
Authors: John-Ross D Clarke, Angela Y Higgins, Yongfei Wang, Kamil Faridi, Jeptha P Curtis, James V Freeman, Daniel Friedman
Journal: Circulation (2022)

Introduction: Pre-procedure cardiac computed tomography (CT) or magnetic resonance imaging (MRI) prior to percutaneous left atrial appendage occlusion (LAAO) has many theoretical benefits but data on its association with periprocedural safety and effectiveness is limited. Hypothesis: Pre-procedure imaging has the potential to improve the safety and effectiveness of LAAO. Methods: We evaluated patients in the NCDR LAAO Registry who underwent LAAO between 1/2016 and 6/2021 to compare the safety and effectiveness of LAAO procedures by use vs. non-use of pre-procedural CT/MRI. Study outcomes included implant success (deployment and release of device), device success (device released with peri-device leak &lt;5mm), and procedure success [device released with peri-device leak &lt;5mm and no in-hospital MAE (major adverse effects)]. Multivariable logistic regression was used to assess the relationship between pre-procedure imaging and outcomes. Results: Pre-procedure CT/MRI was used for 18.2% (n=20,851) of the 114,384 procedures in this study and significant variability was noted by hospital ( Figure ). CT/MRI use was more common among government and university hospitals, larger hospitals, non-teaching hospitals, and hospitals in the Midwest and south, and was less common among patients with uncontrolled hypertension, abnormal renal function, and no prior thromboembolism. Overall rates of implant success, device success, and procedure success were 93.4%, 91.2%, and 89.4%. Pre-procedure CT/MRI was independently associated with an increased likelihood of implant success (OR 1.08, CI 1.00-1.17), device success (OR 1.10, CI 1.04-1.16), and procedural success (OR 1.07, CI 1.02-1.13) There was no significant difference in risk for MAE (OR 1.02, 0.92-1.12). Conclusions: Pre-procedure CT/MRI was used 1 in 5 LAAO procedures and was independently associated with higher likelihood of implant success, device success, and procedure success, but no difference in MAE.
Abstract 12272: Pericardial Decompression Syndrome Following Low Volume Pericardiocentesis for Malignant Cardiac Tamponade
Authors: Alexandria Clarke Kregor, Spencer Deleveaux, Nerissa Fernandes, Samir Patel, Anjali Joshi
Journal: Circulation (2022)

Introduction: Cardiac tamponade is a life-threatening condition requiring emergent intervention. Pericardial decompression syndrome (PDS) is a rare complication that presents as acute ventricular dysfunction following pericardiocentesis with a mortality rate up to 29%. In this case, we present a patient with PDS who developed cardiogenic shock following pericardiocentesis for cardiac tamponade. Clinical course: A 58-year-old female with no significant cardiac history presented with chest pain and dyspnea. Computed topography revealed a mediastinal mass and large pericardial effusion. Transthoracic echocardiogram (TTE) demonstrated the effusion with tamponade physiology. Left ventricular (LV) systolic function was preserved at this time. A total of 450ml of serosanguinous fluid was removed by pericardiocentesis, with minimal residual volume around the RV and a large effusion remaining around the LV. Repeat TTE 14 hours later revealed severe global hypokinesis and biventricular failure with an LV EF of 15%. The patient was started on inotropic therapy and transferred to our tertiary care center. Continuous diuresis and vasopressor therapy were initiated. Once stable, the patient was taken for pericardial window with further removal of 600ml of fluid. Subsequent TTE demonstrated recovery of LV systolic function to 47%. Discussion: Our patient developed cardiogenic shock secondary to biventricular heart failure following pericardiocentesis. This presentation is concerning for pericardial decompression syndrome. While the exact mechanism of PDS is not known, the current hypothesis postulates that drainage of fluid compressing the RV leads to a sudden increase in venous return. This abrupt change causes septal bowing and decreased LV systolic function. Some sources recommend draining pericardial fluid in smaller quantities; however, PDS may still occur at smaller volumes as was seen in our patient. PDS is a rare but life-threatening complication that requires vigilance post-pericardiocentesis regardless of volume removed.
Abstract 12023: The Serum ACE2 Molecule in SARS-CoV2 / COVID-19 Infection and Its Potential Prognostic and Therapeutic Role (ACCEPT Study)
Authors: Francesco Fioretti, Antonio Maria Sammartino, Francesco Ravasio, Angelica Praderio, Lorenza Inama, Matteo Pagnesi, Francesco Pallotti, Savina Nodari
Journal: Circulation (2022)

BACKGROUND: It is well known that the entry of the SARS- CoV-2 into cells is mediated by the binding between the virus Spike-glycoprotein (S) and the membrane ACE2-receptor (ACE2R). When SARS-CoV-2 binds to ACE2R, a down-regulation of ACE2R occurs, playing a crucial role in the inflammatory response. Also ACE2 deficiency is thought to play an important role in the pathogenesis of SARS-CoV-2 infection, and could be particularly harmful in subjects with pre-existing ACE2 deficiency, for example due to advanced age, the presence of DM, arterial hypertension or pre-existing heart disease, including HF. AIM OF THE STUDY: we aimed to identify predicting factors of a higher risk in terms of severity of the clinical course and worse prognosis in the population of the Brescia area, affected by a large number of cases in the first period of COVID-19 outbreak. In particular, we aimed to verify whether there is correlation between levels of serum ACE2 (sACE2) and the risk of SARS-CoV-2 infection, as well as between sACE2 and the different severity of the clinical manifestations of COVID-19 in pts with and without CV diseases. Methods: we enrolled subjects with previous documented SARS-CoV-2 infection and divided they into three groups: pts with asymptomatic course; pts with symptomatic course but without the need for hospitalization for COVID-19; pts with severe symptomatic course requiring hospitalization in ICU. Blood samples were taken for sACE2 dosage. We compared the concentrations of sACE2 in these groups in relation to the age, clinical course, comorbidities, and ongoing therapies. Results: at March 2022, we enrolled 178 pts, 51 (28%) were hospitalized for COVID-19, whereas 78 (44%) had symptomatic course without hospitalization and 49 (28%) were completely pauci-asymptomatic. Only 6 pts (4%) had myocarditis or pericarditis SARS-CoV-2-related. Between hospitalized pts, male sex (67%), older age and higher BMI were most frequent. Moreover, chronic heart failure (20%), a diagnosis of cardiopathy (29%) and AF or atrial flutter (22%) were most frequent. PERSPECTIVES: ACCEPT study will help to clarify the relationship between ACE2 molecule, the risk of SARS-CoV2 infection and the severity of clinical presentation of COVID-19 in pts with or without CV diseases.
Abstract 11929: Rare Presentation of Fetal Long QT Syndrome With 2:1 Atrioventricular Conduction
Authors: Joyce Woo, Sara Cherny, Stephanie Chandler, Nicholas Brown, Hailey Funk, Janette F Strasburger, Ronald Wakai, sheetal patel
Journal: Circulation (2022)

Case Presentation: A 34 year-old G2P1 mother with Long QT syndrome Type 2 (LQTS2), history of sympathetic denervation, implantable defibrillator, and strong family history of LQTS2 including sudden death, presented to fetal cardiology at 29+3 weeks gestation with fetal 2:1 atrioventricular (AV) conduction and a ventricular rate of ≈60 bpm on fetal echocardiogram without hydrops. Findings persisted at 30+5 weeks by echo. The patient’s KCNH2 p.Met645Ile variant was previously classified as a Variant of Uncertain Significance, but segregation analysis of the family by a genetic counselor upgraded the variant to Likely Pathogenic. Prior to pregnancy, the patient was taking nadolol, then started on 2000 IU of vitamin D at 30+6 weeks due to borderline vitamin D level. Within 24 hours of initiating vitamin D, fetal magnetocardiography (fMCG) demonstrated predominant sinus rhythm with 1:1 conduction at ≈120 bpm and occasional 2:1 AV conduction. The QTc measured ≈550 msec during 1:1 conduction, and ≈720 msec during 2:1 conduction. Following the multidisciplinary diagnosis of fetal LQTS, several decisions were made. The patient declined amniocentesis, as the risk outweighed the benefit of additional genetic information. Daily home fetal heart monitoring, with goal heart rate 70-170 bpm, allowed for fewer fetal echos. Maternal vitamin D intake was liberalized to 4000 IU/day. Follow-up fMCG was recommended to exclude late-onset Torsade de Pointes, which would require transplacental treatment and complex perinatal management. Discussion with electrophysiology outlined longitudinal outcomes for the family, including potential need for neonatal pacing wires. Discussion: LQTS affects ~1/2,500 live births, with even fewer presenting with fetal AV conduction abnormalities. Optimized maternal vitamin D level may be associated with improved conduction. A multidisciplinary approach is crucial in diagnosis and management of these high-risk fetuses.
Abstract 12375: Gender-Related Differences in the Prognostic Value of Biomarkers in Patients With Acute Chest Pain Without Myocardial Infarction
Authors: Gard M Myrmel, Ole-Thomas Steiro, Hilde L Tjora, Jorund Langorgen, Rune O Bjorneklett, Oyvind Skadberg, Vernon Bonarjee, Øistein Mjelva, Kjell Vikenes, Torbjorn Omland, Kristin Moberg Aakre
Journal: Circulation (2022)

Introduction: Patients presenting with acute chest pain may carry an increased risk of cardiovascular events even though myocardial infarction (MI) is excluded. Whether there are gender-related differences in the prognostic value of biomarkers in this patient population is unclear. Methods: We performed a post hoc analysis of the WESTCOR trial that included 1319 patients (779 male and 540 female) admitted with acute chest pain without MI. Biomarkers included peak high sensitivity cardiac troponin T (hs-cTnT), peak high sensitivity cardiac troponin I (hs-cTnI), N-terminal proB-type natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15) and C-reactive protein (CRP), all from Roche Diagnostics. Cox regression analysis was performed for ln-transformed biomarkers in unadjusted models and models adjusting for age, hypercholesterolemia, current smoking, diabetes, hypertension, previous MI and eGFR &lt;60 ml/min/1.73m2 in predicting a combined endpoint of all-cause mortality, future MI and hospitalization for acute heart failure. Gender differences in C-statistics were also estimated. Results: During a median follow-up of 1545 days (range 4 - 2208), the endpoint occurred in 11% of females and 13% of males (p = 0.212). Peak biomarker levels are shown in Table 1a. In the unadjusted and adjusted Cox regression analysis, increasing levels of all biomarkers were associated with a higher risk of death and cardiovascular events in women, but the interaction by gender was only significant for NT-proBNP and GDF-15 ( Table 1b ). The C-statistic for prediction of the endpoint was significantly higher for hs-cTnI and GDF-15 in women than in men ( Table 1c ). For hs-cTnT, NT-proBNP and CRP the difference in C-statistic between genders was non-significant. Conclusion: Circulating concentrations of cardiac troponins, GDF-15 and NT-proBNP seem to be associated with a higher risk of death and cardiovascular events in women compared to men.
Abstract 12237: Transcatheter Aortic Valve Replacement in Very Low Gradient Aortic Stenosis
Authors: Connor Raikar, Erin Crawford, Abigail Baldridge, Zhiying Meng, Akhil Narang, charles davidson, S C Malaisrie
Journal: Circulation (2022)

Introduction: Transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement is recommended for symptomatic patients with high-gradient aortic stenosis (HGAS) and certain patients with low-flow, low-gradient aortic stenosis (LGAS). While TAVI may be beneficial in LGAS (mean pressure gradient (MPG) &lt;40 mmHg), the outcomes of TAVI in very low-gradient AS (VLGAS) patients (&lt;25 mmHg) is under-reported. Methods: This retrospective cohort study analyzed 1269 patients who underwent TAVI at a multi-disciplinary, tertiary-care center. Patients with severe aortic stenosis were divided into VLGAS (≤25mmHg), LGAS (&gt;25 mmHg up to 40 mmHg) and HGAS groups (≥40 mmHg), using MPG derived from transthoracic echocardiography. Symptom improvement was measured by New York Heart Association (NYHA) functional classification at baseline, 30-days, and 1-year. Mortality and rehospitalization were secondary endpoints. Between group differences were evaluated with chi-squared tests. Results: Patients with VLGAS had improvement in NYHA functional class after TAVI that was similar to those with LGAS and HGAS (figure). While symptom improvement was similar between groups at 30 days (86% in VLGAS, 84% in LGAS and 85% in HGAS, p=0.46), VLGAS was associated with inferior symptom improvement at 1 year (76%, 87%, and 89%, respectively, p&lt;0.01). One-year rehospitalization rates were higher in patients with VLGAS than in patients with LGAS or HGAS (28%, 21%, and 17%, respectively, p =0.014). Mortality at 1-year did not differ between groups (p=0.65). Conclusion: TAVI improves symptoms in most LGAS patients, including those with VLGAS. More VLGAS patients with either no change or worsened symptoms after TAVI may be correlated to increased rehospitalization.
Abstract 11918: Improving Quality of Care for Patients With Valvular Heart Disease in a Learning Health System
Authors: Abigail S Baldridge, Parmeen H Bindra, Shruti Cruz, James D Thomas, Akhil Narang, Faraz S Ahmad
Journal: Circulation (2022)

Introduction: Delayed treatment of valvular heart disease (VHD) is associated with higher mortality and adverse event incidence. In a large, integrated health system, we developed and piloted a digital health solution embedded in the electronic health record (EHR) to identify, triage, and streamline evaluation of patients with VHD. Methods: The initiative began May 2021 with agreement of our team members and stakeholders for prioritization of the project and implementation. Structured echocardiographic data were made available in electronic data warehouse. SQL-based disease classification algorithms based on published guidelines were built for aortic stenosis (AS), mitral regurgitation (MR) and tricuspid regurgitation. Echocardiograms with suspected VHD were pushed daily into a reporting dashboard and smartform we built within the EHR. Nurse coordinators responsible for VHD patient care tested the platform, and we iteratively adapted components based on feedback. Performance of AS and MR classification algorithms against historical data were evaluated using kappa statistics. We launched the program in March 2022 and report the initial results. Results: Between August and October 2021, 650 echocardiograms were reviewed by a nurse coordinator. Agreement between the guideline-based algorithms and chart review was moderately high (0.64 for AS and 0.86 for MR). Between March and May 2022, 7180 echocardiograms with suspected VHD were surfaced in the EHR for 6588 patients. Among 1501 patients prioritized for review based on disease severity, 341 patients were referred to the valve clinic for procedural intervention, 783 patients are under watchful waiting, and 377 patients were determined to unlikely benefit from valve interventions. Conclusions: By leveraging data from echocardiogram repositories, it is feasible to implement a VHD quality improvement program within a learning health system. This requires a diverse and interdisciplinary team for development, implementation, governance, and continued iteration of EHR-embedded digital health tools to improve quality of care. While we focused on VHD, our methodology and infrastructure allow for expansion and leverage into other therapeutic domains within cardiovascular disease and beyond.